Racism affects health through both direct means (for example, the chronic activation of the hypothalamic-pituitary-adrenal axis and associated stress hormones, which increases susceptibility to several chronic conditions [1]) and indirect means (for example, the segregation of people of color into low-resource, low-opportunity neighborhoods [2]). In recent years, public health has embraced the promotion of health equity as a core component of the sector’s mission, goals, and strategies, recognizing that achieving the highest possible level of health for everyone requires dismantling racial inequities [3]. Since there is no one defined pathway to health equity, local public health professionals, community-based organizations and other allies must develop their own locally sensitive blueprints for replacing social, economic and environmental structures that reinforce inequity with ones that promote equality.

As a result, health equity advocates have focused on systems and policies as disparate as criminal justice and economic development, each of which influences opportunities over the life course [4]. But what of more subtle influences—for example, memorials many historians view as government-sanctioned artifacts of white supremacy, intended to constantly remind people of color where they rank in the social order [5]? Is there a public health case to be made for changing facets of the built environment that shape the narrative of place, in the same way that public health has advocated for built environments that promote physical activity and access to healthy food?

Themes from the June Roundtable on the Promotion of Health Equity Workshop

The narrative of place played a prominent role during the most recent meeting of the Roundtable on the Promotion of Health Equity at the National Academies of Science, Engineering, and Medicine, held on June 13 in Prattville, Alabama (a suburb of Montgomery). One session featured Felicia Lucky of the Black Belt Community Foundation (based in Selma, Alabama), Ashley Browning from the Appalachian Community Fund (based in Knoxville, Tennessee), and Dolores Roybal from the Con Alma Health Foundation (based in Santa Fe, New Mexico). Each spoke of their efforts to reframe the dominant narratives about their regions from those that emphasized deficits and needs to those that honor assets, tradition and culture.

The roundtable’s location presented a complex counterpoint to the communities featured in these speakers’ descriptions of their efforts to create environments that affirm a full representation of a community’s narrative. In Montgomery, local and state governments have erected and authorized 59 separate markers and memorials glorifying the Confederacy—more than any other city in the United States. These monuments include a towering 88-foot statue erected on the grounds of the Alabama capitol in 1898, whose inscription reads that it is dedicated to “the knightliest of the knightly race.”

This year has witnessed high-profile attempts to remove Confederate memorials and other symbols that many see as markers of white supremacy, as well as the sometimes violent backlash from those who wish to preserve them. The most prominent example occurred in Charlottesville, Virginia, where the proposal to remove a statue honoring Robert E. Lee—who led an armed secession from the United States, in large part to preserve slavery—was met with an organized and violent effort that resulted in one death and multiple injuries [6]. Earlier this year, New Orleans removed four Confederate memorials after Mayor Mitch Landrieu declared the Confederacy to be on “the wrong side of humanity” [7]. The company that the city originally contracted to remove the memorials withdrew after the owner received death threats and had his car firebombed.

While Confederate memorials and monuments represent the most prominent facets of the built environment that celebrate white supremacy, they are by no means alone. Another statue on the grounds of the Alabama capitol commemorates Dr. J. Marion Sims, often described as the “father of modern gynecology.” Dr. Sims earned this honor by performing experimental surgeries on enslaved women in the 1840s without informed consent and without anesthetic (ether had been introduced as a surgical anesthesia several years earlier). The fact that Dr. Sims thought so little of black lives is not entirely surprising—but the fact that the Alabama state government thought to venerate him and place his statue in a prominent location overlooking Montgomery (57 percent of whose residents are African American) sends a powerful signal that white prestige is more important than black lives.

Promising Community Strategies to Reframe the Narrative of Place

Is there a public health case to be made for removing these physical markers of white supremacy and replacing them with environmental features that represent a more complete expression of the American experience—one that celebrates the culture and contributions of communities that have historically been marginalized or disenfranchised?

Several promising efforts are already underway. For example, the Equal Justice Initiative (EJI) is working to counterbalance the veneration of the Confederacy with the erection of public monuments recognizing the racial terror lynchings that claimed the lives of more than four thousand African American men, women, and children throughout the South from the end of Reconstruction through World War II [8]. Earlier this year, the staff of EJI completed an intensive engagement process that resulted in the erection of a memorial to Anthony Crawford, who was publicly lynched in the town square of Abbeville, South Carolina for refusing to sell his cottonseed at a price lower than that offered to white farmers [9]. EJI’s engagement process included descendants of Anthony Crawford and multiple community constituencies. Crawford’s family was forced to abandon his 427-acre farm (which was subsequently appropriated by white landowners) and flee north. This marker serves as a counterweight to a Confederate memorial that also stands in Abbeville, and tells a more complete narrative of the town. EJI has received requests from other cities to erect similar memorials.

Another way in which historically disadvantaged communities have reclaimed the narrative of place is through creative placemaking—the practice of integrating art, culture and community-engaged design in comprehensive community development [10]. One example of how communities have used creative placemaking comes from Saint Paul, Minnesota, where the Asian Economic Development Association (AEDA) has led a collaborative effort in the Frogtown and Rondo neighborhoods to celebrate the diverse cultures that call these neighborhoods home. Through food, performance, festivals and physical transformation, AEDA and its partners have created a sense of pride and social cohesion, while revitalizing the neighborhoods on their own terms [11].

Several other promising efforts can be found in Communities in Action: Pathways to Health Equity, published this year by the National Academies Press [12].

Public Health’s Role in Creating Equitable Environments and Narratives

While racism has been shown to affect health, there is no scientific parts-per-million equivalent for exposure to racism as there is for other toxins—and the movement to dismantle structural racism should not be held to such an artificial standard to justify its validity. Just as the public health field does not need to demonstrate that particular gun control legislation would have prevented a specific mass shooting to advocate for stricter gun laws, or that the lethality of hurricanes have increased by a specific percentage to advocate for climate action, we should not feel obliged to demonstrate a direct causal pathway between venerations of white supremacy and its continuing effects on populations that have been traumatized over generations by racial violence, segregation and disadvantage.

Similar to the public health assertion that there is no safe level of exposure to lead or to cigarette smoke, one could argue that there is no safe level of exposure to structural racism. While facets of structural racism—such as disparate access to capital or disproportionate sentencing practices—may be resolved through years or decades of unwinding multiple policies and institutional norms, removing physical artifacts erected by local governments and widely interpreted as markers of white supremacy can be fairly straightforward, as illustrated recently by the City of Baltimore [13]. Public health has worked to reduce and eliminate exposures known to contribute to health disparities in other facets of the physical environment, and the removal of monuments to white supremacy can be viewed as an extension of this robust tradition.

Abstract | Businesses are gaining a greater understanding of the effect that employee health and the health of the communities in which businesses reside has on their success. No matter the size, type, or location of a business, many of them are proactively looking to improve health in the communities where they operate. To better understand businesses’ growing relationship to community health, the US Chamber of Commerce Foundation Corporate Citizenship Center (USCCF) partnered with the Action Collaborative on Business Engagement in Building Healthy Communities (the Collaborative), a convening activity of the National Academies of Sciences, Engineering, and Medicine’s Roundtable on Population Health Improvement. This paper is a product of that partnership, exploring the business motivation for investing in community health, the processes involved in that effort, and the challenges stakeholders faced when pursuing these initiatives.

Introduction: The State of Workers’ Health in the United States

American labor productivity has steadily increased over the past several decades, augmenting businesses’ reliance on the workforce to sustain their revenue and growth [1]. This economic and business advancement is heavily influenced by the health, or the lack thereof, of the 144 million currently employed Americans. Statistics offer a sobering look at the state of health among the working-age US population:

Seventy-one percent of Americans age 20 and over are overweight or obese (body mass index, or BMI, equal to or greater than 25). Thirty-eight percent are obese (BMI equal to or greater than 30) [2].

The Effect on Businesses: The cost of unhealthy employees to businesses is significant to their bottom line. Obese men incur $1,152 more in direct annual health costs than do men of normal weight, and obese women incur $3,613 more than do women of normal weight [3].

Twenty-five percent of Americans age 18 and over had at least one heavy drinking day (five or more drinks for men and four or more drinks for women) in the past year [4].

The Effect on Businesses: Partial-day absenteeism because of smoke breaks cost an estimated $13 per workday, accumulating to an additional $3,077 per year per worker. Health care costs for smokers are about $2,056 per year more than the costs for nonsmokers [7].

Seven percent of individuals 18-39 years old and 10 percent of 40-59-year-olds have moderate to severe depressive symptoms [8].

The Effect on Businesses: Workers in the United States who, at some point in their lives, have received a diagnosis of depression miss an estimated 68 million more days of work each year than their counterparts who have not been depressed—resulting in an estimated cost of more than $23 billion in lost productivity annually to US employers [9].

Moreover, a World Economic Forum report (2011) estimates a cumulative economic output loss of $47 trillion over the next two decades from noncommunicable diseases such as cardiovascular disease, chronic respiratory disease, cancer, diabetes, and mental health, representing 75 percent of global GDP in 2010 [10].

The Importance of Business Participation in Community Health

Business investment in health in the twenty-first century has become increasingly common as the private sector seeks to improve the health of their employees as part of their corporate citizenship efforts, find new business opportunities, and ultimately improve their return on investment (ROI) both socially and financially. Health and wellness programs, run by businesses or offered through employee insurance plans, are now standard at large businesses and are gaining traction among small and medium-size enterprises (SMEs). As businesses acknowledge the importance of health in the workplace, they have also begun to recognize the relationship between their employees’ health and the communities where their employees (and their families) and customers live. At the end of the workday, employees and customers still return home to communities that may be food deserts, have poor infrastructure, or have limited access to good-quality health care. Improving community health—long considered solely the responsibility of the public sector—is gradually being embraced by the private sector [11].

To gain more insight into businesses’ relationship to community health, the US Chamber of Commerce Foundation Corporate Citizenship Center (USCCF) partnered with the Action Collaborative on Business Engagement in Building Healthy Communities (the Collaborative). The Collaborative is a convening activity of the National Academies of Sciences, Engineering, and Medicine’s Roundtable on Population Health Improvement composed of private, public, and nonprofit sector parties that endeavor to improve health in US communities. This paper is part of the Collaborative’s effort to promote business engagement in strategies for improving community health with a focus on the health and economic well-being of businesses, workers, and communities.

Typically, community-based public health–related programs have been tied to healthy behaviors and clinical care. In recent years, however, public health practitioners have taken a more expansive view of community health, its effect, and the stakeholders involved in improving it. As defined, community health refers to the health status of a specific group of people, or community, and the actions and conditions that protect and improve the health of the community. Those individuals who make up a community live in a somewhat localized area under the same general regulations, norms, values, and organizations [12].

A framework for understanding the different factors and potential opportunities for interventions that influence population health is offered by the Robert Wood Johnson Foundation’s County Health Rankings & Roadmap (CHRR) (see Figure 1). This framework provides a useful graphic representation of the factors that contribute to health outcomes.

Figure 1 | County Health Rankings & Roadmap | Source: Reprinted with permission from the University of Wisconsin.

Most workplace wellness programs are structured to address improvement in healthful behaviors and clinical care without including external socioeconomic and environmental interventions (e.g., access to green spaces, active transportation, healthy housing, and nutritious foods) that also influence employee health [13]. Given the sheer amount of time that people spend outside of the workplace, work-site-based wellness programs offer only a partial solution to a complex problem centered in a company’s home community. For example, some major industries, such as retail and manufacturing, are more likely to be in counties with poor health, emphasizing the need to confront health issues outside the workplace [14].

However, there are businesses investing in community health. Researchers with the Health Enhancement Research Organization (HERO) cited several reasons for doing so:

Enhanced reputation in the community as good corporate citizens

Cost savings that would increase over time

Job satisfaction

Healthier, happier, and more productive employees

Healthy, vibrant communities that draw new talent and retain current staff

Compliance with regulations

Enhanced consumer health [15,16,17]

Common Business Strategies to Invest in Community Health

Some of the common strategies that companies have used to invest in community health are highlighted below in Boxes 1-3 [18].

Philanthropy, Health Advocacy, Employee Volunteering

Efforts such as targeted philanthropic giving, participating in health advocacy, employee volunteering, and employees serving on the boards or advisory councils of health initiatives further extend the potential of businesses to positively influence community health. Under the CHRR framework, many businesses’ corporate citizenship initiatives contribute to overall community health and well-being. Business environmental sustainability programs, for example, can have a direct effect on community health through better air, water, and soil quality. Furthermore, the community participation associated with employee volunteer programs has been demonstrated to improve health and may therefore also directly serve to promote employee health [19] (see Box 1).

Innovative Products and Services

Businesses can also directly affect community health through their products and services. The work of Michael Porter and Mark Kramer on creating “shared value” is a model that some businesses are using to change their products and services to generate greater innovation and growth for the company while simultaneously providing greater benefits to society [14,16,20,21]. As consumers have become more health and socially conscious, businesses have innovated to meet their demands, influencing community health in the process. The health care industry has a natural advantage to improving community health given its business goals, but businesses outside the health care industry may also use their products and services to improve community health (see Box 2).

Partner with Other Stakeholders

Individual and community health is a product of the interaction of societal, economic, and environmental factors. Given these interrelated factors that influence health, businesses rarely execute a program without other community stakeholders. Partnering with external organizations on community health initiatives enables businesses to improve the health of their workforce through community and workplace health promotion; increase human capital through employee recruitment, engagement, and retention; and profit from business opportunities to develop healthful products and services that respond to market demands [14,22]. Such partnerships consist of nonprofit or public sector organizations, trade associations, or local civic organizations, all of which provide opportunities for businesses to access existing community health programs or launch new initiatives (see Box 3).

Partnering with external organizations can also serve as a way to overcome some of the barriers that business faces, particularly if they are outside the health care industry, when considering how to extend health initiatives outside the workplace. The following are some of the barriers for businesses engaging in community initiatives:

A lack of understanding, strategy, or resources

The complexity of community health problems

A lack of trust or experience between businesses and partnering organizations

Difficulty in navigating policies and regulations

A need to shift leadership philosophy [17]

Data and metrics have become progressively integrated into business activities as big data analysis and technological advancements allow for the mining of myriad data types [15,23]. However, comprehensive assessment of health outcomes can add a layer of complexity to business participation in such endeavors. These are some of the challenges businesses face in assessments:

Measuring cause and effect. Because numerous factors can contribute to the health of a community and there are frequently other programs attempting to effect change as well, determining whether a business’s particular program had any influence on health outcomes can prove difficult, particularly in communities with a wide array of health challenges or a number of different community health programs.

Internal business capacity. Assessing a program requires dedicated funding and a skill set that may not be common to businesses, especially smaller and midsized ones. In addition, measuring health outcomes is a multiyear commitment that can be daunting to any organization to manage.

Balancing business and programmatic ROI. Given the quick pace of business and a focus on immediate results, health outcomes assessment is a more extensive process that may not coalesce with business needs and desires.

Use of data. Basic, narrative data from community health programs is usually collected to enhance business marketing and promote corporate citizenship activities. Businesses may not be interested in more in-depth analysis, and senior management may not require it to justify continuing programming.

A solution to these challenges is partnering with an organization or academic institution that has the capability of assessing health outcomes. Finding an able partner may exceed the commitment a business is willing to make, depending on its goals for a community health program.

Research Questions

To date, little research exists on the differences in community health involvement based on business size or the role that member-based organizations (e.g., trade associations, local civic organizations, and so on) in community health can play in connecting businesses to communities. This paper therefore explores what, if any, variations there are in the case of large companies compared with SMEs and member-based organizations in community health efforts.

This paper is based on research conducted to address several questions about businesses and community health:

Why are businesses investing in community health? What is their motivation?

Do businesses see programs that focus on social, economic, and environmental factors in their communities as efforts related to community health?

What types of community health activities are businesses engaged in?

What processes do businesses undertake to establish and run community health programs? What challenges have businesses faced?

Does community health engagement vary by the size of the business?

How does private enterprise engagement in community health differ from that of member-based organizations (e.g., trade associations, civic organizations)?

What role do member-based organizations play in connecting businesses to communities?

To answer these questions, in-depth interviews were conducted with a variety of entities involved in business programs in community health. The authors spoke with people in two larger businesses (more than 500 employees), three small and medium-sized businesses, two trade associations, one state civic organization, and one city civic organization—all doing work in community health—in fall 2016. The authors asked them about their involvement in community health and the steps they undertake to develop, run, and evaluate their programs (see Box 4 for a list of interviewees and see Box 6 for the interview questionnaire). Follow-up and informal conversations with a broader assortment of businesses connected through the Collaborative and through USCCF helped frame the findings of the in-depth interviews by including geographic, systematic, or programmatic context.

In this paper, the authors focus on partnership programs and business products and services that can transform community health. Though other activities such as philanthropic giving can contribute to community health efforts, this investigation specifically probes how direct business participation affects the health of communities. Also, although internal employee wellness programs occasionally came up in interviews, our research does not concentrate on them. This research found that they were too varied and generally beholden to too many policies and regulations to include in an analysis such as this, although the efficacies of some workplace wellness programs can be seen in the work of Berry et al. (2010) [24]. Finally, for similar reasons, the research touches upon the involvement of the public sector in business community health but do not specifically cover public-private partnerships.

Findings: Business Motivation for Investing in Community Health

Businesses commonly cited five reasons for getting involved in community health [15]:

Improve health of employees and their families to further reduce health care costs.

Enhance organizational reputation.

Engage in economic development that stimulates new business and increases sales for current business.

Create a vibrant, safe community to draw new talent and retain the current workforce.

Interviews with businesses of varying sizes and member-based organizations engaged in community health reveal that these groups are motivated by dual purposes: the drive and passion to improve health in their communities and the desire to enhance business ROI. When probed, the vast majority of businesses and member-based organizations interviewed agreed that all the reasons cited in the HERO report were motivations for their businesses and business members (in the case of the member-based organizations) to invest in community health. Some of the businesses said that enhanced organizational reputation and the creation of new business and increased sales were not direct reasons for their involvement in community health programs but were by-products of their initiatives.

Businesses also expressed that their investment in community health reflects a genuine concern about communities, particularly those communities where the businesses are located. Giving back, some said, is “the right thing to do” since it is the community that keeps them in business. For those companies whose corporate priorities and mission depend on health, the imperative of their vision is what guides them. The businesses and member-based organizations believe they understand the health challenges faced by people in their communities and want to be part of the solution.

Another less common motivation for becoming involved in community health is to fill an unmet need in a community. As the largest employer in several rural communities in southern Indiana where health care professionals are sparse, Jasper Engines has established wellness clinics to help employees and their families more easily seek care, saving employees and their families hours of travel time to see general practitioners or specialists. The company also organizes a health fair and 5k run to involve the broader community in wellness activities and improved health.

The business member-based organizations—the Greater Philadelphia Business Coalition on Health (GPBCH), the Wellness Council of Indiana (Wellness Council), and the Grocery Manufacturers Association (GMA)—thought that although members join for many reasons, some of their members specifically joined so that they could connect to communities and participate in community health efforts with other like-minded businesses. Some of the reasons for membership in their organizations that they cited are permitting a business to collectively support community health initiatives when they do not have the capacity to run a community health program alone, using the member-based organization to expand their community health outreach efforts, and providing businesses access to other businesses to share locally focused lessons learned or best practices in community health.

The Nuts and Bolts

The large and medium-size businesses that we investigated and interviewed house their community health programs in a variety of corporate divisions: corporate social responsibility, human resources, risk management, and marketing/sales, demonstrating the challenges that external, or even internal, groups may experience in identifying the principal liaison for community health programs. In the smallest organization interviewed, Ted’s Shoes and Sport with 10 employees, the owner of the business, Ted McGreer, handles community health programming personally. As a very small business involved in community health, Ted’s Shoes and Sport empowers employees to get involved in the decision-making process. Every Monday, the full staff reviews submissions that have come in the prior week for community health partnerships and sponsorships. They then collectively make decisions about the community health efforts that Ted’s Shoes and Sport will pursue.

Businesses mostly identify programs focusing on social issues, economic issues, and/or the environment, all identified as health issues in the CHRR framework, as related to community health. They recognize that health is multifaceted and that programs concerning these issues influence health and well-being. However, the programs of these businesses typically focused on traditional healthful behaviors or clinical care.

In terms of funding for programs, budgets for community health programs in the businesses interviewed were created by those managers in charge of them. Community health initiatives at GPBCH, the Wellness Council, and GMA are funded from a variety of sources, including membership dues, and supplemented with funds from sponsorships, trainings, consulting, grants, or special member assessments. Among those businesses and member-based organizations that have a board of directors, the board approves the budget for community health. Although a budget for community health programs is established, several entities interviewed said that there is flexibility regarding additional programs, which makes them more versatile so they can pursue new opportunities.

Partnerships

Ways to determine which community health programs to pursue vary, but partnering almost always took place at all the businesses interviewed. The businesses frequently field proposals for partnerships by nonprofit and other community groups interested in improving community health and programs. However, we found that the businesses also initiate relationships with specific partners for programs related to the partner’s expertise.

Regardless of who initiates the partnership, businesses often have criteria for the programs they want to invest in that are tied to their corporate priorities or mission. Whereas some community health programs of the interviewees were broad reaching, affecting the general population, more frequently they focused on specific groups or needs related to the businesses’ core competencies or markets. Once partnerships are formed, responsibilities and expectations between companies and local health nonprofits are usually established informally, except in instances with concrete deliverables or where funds are exchanged.

Member-based organizations, which are also pursued by community health groups to create joint initiatives, frequently solicit feedback from their membership to help decide programmatic direction. With the member-based organizations, the membership often decides which communities to target.

Among those partnership elements that were common to both businesses and the member-based organizations, the majority of interviewees said that government entities had been involved in at least one community health program with them. As for the contractual aspects of partnerships, both groups said that their partnerships in community health are typically informal, i.e., they do not involve written contracts or agreements unless they entail specific deliverables or the exchange of funds from one organization to the other.

Champions

Each of the businesses and member-based organizations found that a champion was essential to the realization of community health programs. For some of the interviewees, the person in charge of community health programs at the business or member-based organization was the natural champion because it was his or her responsibility to organize community health activities and create programs that serve the best interests of the business or organization. In cases where there was no existing director of community health programs, the organizational role and title of that person varied. At Jasper Engines, for example, duties were shared between the directors of the health and safety department and the department of corporate compliance and health care.

Once the business and nonprofit partners form a community health program, other champions may appear to trumpet the cause. In the case of GPBCH and the Wellness Council, the organizations have rallied their members to inform them of the importance of their programs. For example, GPBCH encourages member businesses to adopt a healthy meetings policy to serve nutritious food at business meetings. GMA has also served as an incubator for health and wellness initiatives that are supported by a self-selected and highly motivated group of companies and company leaders that include many GMA members.

For all the interviewees, strong leadership from business or organizational senior management played a key role in community health program support. Ted McGreer, the owner of Ted’s Shoes and Sport, had a history of dedication to community service and health as a member of Rotary Club, the community service organization, and as an avid triathlete. These passions carried into his business once it was launched.

Vitamix CEO Jodi Berg is also a fervent supporter of its community health initiatives, and all business employees carry a vision statement on their work badge to emphasize that they “improve the vitality of people’s lives and liberate the world from conventional food and beverage preparation boundaries” on a daily basis.

In short, businesses strongly feel that the dynamism of a champion and the support of senior management are essential to achieving the goals of community health initiatives.

Types of Programs

Partnering with external organizations was the predominant method for businesses to help improve community health. Such organizations consisted of nonprofit or public sector organizations, trade associations, or local civic organizations, all of which could provide opportunities for businesses or member-based organizations to access existing community health programs.

Among the member-based organizations studied, the community health programs of GPBCH and the Wellness Council are intrinsically oriented toward external partnerships given their missions and organizational structures to serve members in supporting community health. GPBCH is a part of the Philadelphia Health Initiative, a multisector coalition with partners such as the Philadelphia Department of Public Health and STOP Obesity Alliance to prevent obesity and promote healthy weight throughout the community and through workplace programs and policies. As a trade association, GMA joined forces with the Food Marketing Institute to bring consumers Facts Up Front, a voluntary front-of-pack labeling initiative that takes key information directly from the FDA-regulated Nutrition Facts Panel and presents it in a clear, simple, and easy-to-use format on the front of food and beverage packages.

Businesses also have an effect on community health through shared value, using their products and services to address community health issues. The health care industry has a natural inclination to improve community health given its industry focus, but businesses outside the health care industry may also use their products and services to improve community health. Amway, for example, has innovated drinking water treatment technology with its eSpring water filter, integrating ultraviolet disinfection to destroy more than 99.99 percent of the bacteria and viruses commonly found in potable water. Similarly, Texas-based insurance company Higginbotham uses its own company to try out community health programs, such as a tobacco cessation program offered through its county public health department, that the company may eventually recommend to its corporate clients for use in their own wellness programs.

However, shared value and social entrepreneurship are not always paths available to small and medium businesses. Many do not directly engage with consumers as providers of products or services, and others do not have the capacity to change their business models. Instead, most focused on how they could leverage their human capital either internally or externally to promote change in their communities, such as Ted’s Shoes and Sport or Vitamix.

Almost uniformly, businesses were involved in some type of philanthropic giving in community health, through in-kind donations, grant giving, or sponsorship of community health events or organizations. Many large and medium-size businesses have foundations dedicated to philanthropic efforts in community health. Finally, employee volunteerism and, to a lesser extent, participation on the boards or advisory councils of health groups was encouraged.

Measurement and Evaluation (M&E)

Metrics play a valuable role for businesses and their community health programs, but assessing the health outcomes of their programs is challenging for many businesses. All the businesses and member-based organizations interviewed captured narrative data and metrics on participation, the number of units donated and distributed, or similar measurements. Some data collection is more substantial, enabling businesses and member-based organizations to track programs and adjust them when data show that changes may be necessary to improve effect and outcomes.

Some of these data were collected by the businesses themselves; in other instances data were supplied by program partner organizations. The businesses and member-based organizations interviewed do not have dedicated teams or specialists to evaluate programmatic success, so the assessment of health outcomes is limited to situations where a program partner brings that skill set to the collaboration. For example, Jasper Engines partners with an insurance broker that aggregates program data for the business, creates dashboards, and examines data trends over time.

The data, once obtained, are typically used in several ways. On a grand scale, the programmatic data help the business consider the success of a program and potentially whether to partner with a particular organization in the future. Data are also used for corporate citizenship reporting purposes, marketing and other external communications, and, in the case of the member-based organizations, new member recruitment to the organization. And frequently, they are shared with senior management and members to justify the existence of programs and determine the direction of future programming (see Box 5).

Challenges

Several businesses cited differences in work style between the private sector and nonprofit or public sectors as hindering joint efforts on community health programs. Because of differences in pace and bureaucratic hurdles with partners, some businesses and member-based organizations needed to adjust their timelines and expectations when working with the nonprofit or public sectors. Businesses also found that some partners had more capacity to collaborate than others, so vetting was key to determine reliable partners to execute programs.

Alignment of priorities was also mentioned as a challenge. For the member-based organizations whose members may have competing desires, finding a middle ground for a community health program that the majority of stakeholders could agree on was essential. Internal business silos and not having the right people at the table were also mentioned as potential barriers to building strong community health programs. Human resource benefit managers, for instance, may serve as the main business liaison to the member-based organization, but their goals for involvement with the organization may not be aligned with internal corporate affairs or corporate citizenship departments that may be better suited as the main points of contact for initiatives on community health programs.

Adapting to regulations could limit the extent to which businesses could effect change in community health. In one example in a Vitamix program, blenders were donated to local schools to allow them to create healthful smoothies to sell in school cafeterias at a reduced cost for disadvantaged students. The program ran into a roadblock when a regulatory change no longer allowed smoothies to be a reimbursable food item and schools no longer used the blenders as a consequence. Smaller businesses also cited issues such as high business taxes cutting into the amount of funding they can dedicate to community health programs.

Finally, long-term sustainable funding was mentioned as a challenge for small businesses, which have smaller revenue streams, and for member-based organizations, which depend on their membership for income to fund their community health programs.

Lessons Learned

Programmatically, interviewees emphasized the importance of a champion, whether internal or external, in each organization involved in a community health partnership. Strong leadership and vision are required to see programs through and to foster the participation of other organizations. The interviewees also noted that the right stakeholders need to be at the table so that informed decisions could be made efficiently.

Alignment of goals and organizational readiness were also lessons learned. Businesses found that defining actionable programmatic steps with a partner capable of committing the time and effort to the collaboration was essential. For example, with its blender donation program, Vitamix approached schools about their interest in participating in the program but found that quite a few were not prepared to partner. As an alternative, Vitamix established an online application process that defined the criteria for program participation and allowed schools to submit an application when they were ready. The takeaway was that it is sometimes necessary to adjust to the pace of work and other expectations when dealing with partners outside the private sector and unused to working with companies to achieve results.

Communities also need to be ready for business community health programs. The Wellness Council, for example, realized that it needed to slow down its program expansion in larger communities so that it could devote more time to understanding the community health needs in these larger communities and how to best get involved. Recognizing that community dynamics and cultures may differ between communities is crucial to modifying programs quickly to maximize successful implementation.

Ultimately, the businesses and member-based organizations interviewed said that sustaining community health programs is strongly contingent on boards of directors and employee support among businesses. Among the member-based organizations, member support is necessary. Businesses and member-based organizations alike are able to sustain activities if these stakeholders like the programs and see value from them, as shown through measurement and data. Equally important to program sustainability are champions within companies, at partner organizations, and within the communities that they want to improve. Finally, businesses’ continued support of community health is highly contingent on funding and growth in core business activities.

Conclusion

The passion, processes, and types of community health programs that companies engage in do not vary based on their size. Instead, differences in business size have a greater influence on funding and staffing for partnerships. Large and medium-sized businesses have the resources and dedicated staff to lead more numerous or more extensive community health programs. For small businesses such as Ted’s Shoes and Sport, community health programs are fueled by a strong commitment with greater staff involvement.

Local civic organizations and trade associations also play an important role as intermediaries between businesses and communities to improve community health. Large and small businesses alike can benefit from such organizations. The member-based organizations interviewed as well as national groups such as the USCCF’s Health Means Business campaign amplify the voice of businesses and have more influence on community health through access to a broader group of businesses and programs.

More to Learn

This paper adds to the existing literature on community health by exploring the motivations and processes that SMEs and member-based organizations undertake when involved in community health programs. However, it is difficult to extrapolate from this small sample the overall prevalence of SME involvement in community health. A large-scale survey of the SME landscape would be beneficial in this regard.

Many of the businesses investigated had ties to health or nutrition and therefore had a business imperative to become involved in community health programs. Future research may expressly focus on businesses in industries entirely outside of health and nutrition to explore what motivates them to become active in community health.

Findings show that data and metrics are a vital component of any business community health program, but assessing health outcomes is done only occasionally. Previous studies on health metrics in business may provide more guidance to businesses on how to bridge this divide and direction on where to seek assistance from outside organizations on measurement and evaluation [15,23].

Future research may also look at which policies or other public initiatives could be implemented to motivate businesses to extend their well-being and health efforts into communities. Additional regulatory incentives may propel more businesses to action. There are critical reasons for businesses to get involved in community health, and the number of ways to do it with very willing and capable partners is increasing. By taking advantage of these opportunities, businesses have the potential to improve their bottom lines and, more broadly, make a significant contribution to the health of communities.

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Health Enhancement Research Organization (HERO) Employer-Community Collaboration Committee. 2014. Environmental scan: Role of corporate America in community health and wellness. Paper presented to the Institute of Medicine Roundtable on Population Health Improvement, National Academies of Sciences, Engineering, and Medicine, Washington, DC.

National Academies of Sciences, Engineering, and Medicine. 2015. Applying a health lens to business practices, policies, and investments: Workshop summary. Washington, DC: The National Academies Press, 2015.

Small Business Majority. 2014. Small business attitudes on wellness programs. Washington, DC: Small Business Majority. http://www.smallbusinessmajority.org/sites/default/files/research-reports/072114-Small-Business-and-Wellness.pdf (accessed August 7, 2017).

Abstract | Accountable health initiatives, most commonly referred to as accountable communities for health (ACHs), have been implemented nationwide in response to or as a result of contributions from state innovation model grants and community transformation grants, through collaborations with state Medicaid programs, or through other policy and financial incentives. The Center for Medicare & Medicaid Innovation has announced its own Accountable Health Communities Model, which has a $157 million budget over five years [1]. ACHs are best known for their cross-sector approach to addressing population health disparities. These cross-sector interventions are carried out with financial, technical, and planning support from health care delivery systems; philanthropic organizations; local, regional, and state-based public health departments; community-based organizations; consumers of health care; and others. This review of the literature seeks to understand the fundamentals of ACHs including common characteristics, major challenges, and variations in stakeholder engagement to address identified community needs.

Methods

In conducting a systematic review of the literature, we identified peer-reviewed, published articles and gray literature as sources that illuminated elements of accountable health initiatives. Sources describing health care planning and federal initiatives that existed before 2010 (and therefore before the implementation of the Patient Protection and Affordable Care Act of 2010 [ACA]) were not included. However, sources predating the ACA that describe collective impact models and those that describe other intervention elements that are now present in accountable communities for health (ACHs) were included, as reflected in the literature, from sources published as early as 2008. Articles centered upon interventions focused on health care delivery systems, with less emphasis on community engagement (such as sources relating only to accountable care organizations [ACOs]), were excluded. Interventions from sectors outside of the health realm that remain relevant with ACHs were included. Government sources, issue briefs from nonprofit and advocacy organizations, and ACH memos were all included. To be included in the search, sources did not have to explicitly mention “accountable health” or “accountable communities for health,” though those were search terms. Other searches included “collective impact,” “community engagement,” and “cross-sector collaboration.” The search continued until the results reached saturation—that is, new information was no longer able to be gathered from the varied sources. In total, 56 pieces were recognized as appropriate for inclusion in the review of the literature.

Background

The ACA put value-based payment models at the forefront of health care delivery system reform. The Centers for Medicare & Medicaid Services (CMS), through the Center for Medicare & Medicaid Innovation, were tasked with piloting variations of value-based payment models and were offered grants for initiatives ranging from primary care overhaul models (such as patient-centered medical homes, health homes, and comprehensive primary care) to accountable care initiatives (including ACOs). Most of these interventions are created in accordance with the Triple Aim: the belief that to achieve health care delivery system reform, interventions must focus on reduction of health care costs, improvement of patient-centered health care experiences (including quality of care), and improvement in population health [2].

There is a growing body of evidence suggesting that the success of value-based payment models will be closely tied to efforts addressing the behavioral, social, economic, and environmental determinants that play a key role in health inequities and poor health outcomes [3]. In some instances, behavioral and social determinants may exceed genetic factors in terms of predetermining health [4]. Thus, there is growing recognition of the need to address the underlying root causes of poor health outcomes, rather than simply providing treatment [3]. To improve the health of communities, health care delivery systems, public health departments, and community organizations have begun to create cross-sector alignments, embracing “accountable health.”

Accountable health initiatives fundamentally embrace the concept that there is a shared responsibility for the health of a community or patient population across sectors. By focusing on the alignment of clinical and community-based organizations, they offer an integrated approach to health, health care, and social needs of individuals and communities to achieve equity, better population health outcomes, reach a higher quality of health care, and reduce costs [5]. In looking across sectors and aspiring to share accountability, accountable health initiatives differ from ACOs, which hold providers responsible for better management of clinical conditions in a patient population. The term “accountable health” encompasses programs that are sometimes referred to as “accountable communities for health,” “accountable care communities,” “coordinated care organizations,” or “accountable health communities,” among other variations in name. For this review, we will refer to all accountable health initiatives as accountable communities for health, or ACHs. Often, these initiatives are based in a health care delivery system with support from a public health department and are funded through a variety of means, including private, state, and federal grants, as well as a “braiding” or “blending” of community funds and resources. ACHs operate on a continuum, with programs evolving and adjusting to address fluctuations in community need.

Accountable communities for health engage multiple sectors rather than provide interventions based only around a health care delivery system. However, the process by which a health care delivery system or a community embraces a multisector approach to population health varies. ACH interventions have reported financial incentives, changes in patient populations, community interest, catastrophic events, and changing provider responsibilities as catalysts for cross-community collaborative health initiatives [6]. Other common catalysts include collaborative assessments, accreditation, regional planning, and health care delivery system reform initiatives. ACHs are similar to manycollective impact[7] initiatives in that they have a centralized infrastructure, common agenda, shared measurement strategies, continuous communication, and mutually reinforcing activities [7]. Additional factors encouraging multisector collaboration include the ability to share data across sectors and the introduction of a new delivery system and payment models [8].

Sectors engaged in ACHs around the country include business, education, health care delivery, public health, finance, housing, transportation, and community-based organizations. The literature provides many examples of the ways in which cross-sector collaboration leads to effective population health interventions. One study finds that the largest scope of population health activities is carried out by governmental public health agencies, with hospitals, community health centers, nonprofit organizations, and other local government agencies following suit [9]. In the study, communities that achieved comprehensive system capital (a dense network of cross-sector community collaboration) also had the largest scope of population health activities. Over a 16-year study period, communities that successfully achieved comprehensive system capital experienced lower mortality rates from preventable conditions, compared to communities without that capital [9]. It is worth noting that in rural communities, or areas that are underresourced, establishing and maintaining collaboration may be notably difficult, due to lack of proximity. In PacificSource Community Solutions, an ACH located in rural Oregon, members within the governance structure experienced high levels of turnover and burnout, since the heavy lifting of system transformation continually fell upon the same sets of shoulders. However, the ACH sites strong leadership, transparency, and sharing as keys to resilience [10].

The growing burden of chronic disease demands innovative, preventive approaches to address the underlying causes of disease, including those that are social, environmental, and behavioral. Some health care delivery systems have begun to engage the communities that they serve in fostering solutions to population health problems. Community engagement, defined by the Centers for Disease Control and Prevention as “the process of working collaboratively with groups of people who are affiliated by geographic proximity, special interests, or similar situations with respect to issues affecting their wellbeing” [11], has become one of the cornerstones of ACHs. The literature suggests that coordinating efforts between health care delivery systems and community-based organizations (whether health-related or not) have been effective at improving chronic disease management, especially among populations with high rates of diabetes, asthma, obesity, and hypertension [3]. However, it is not merely enough to engage communities in partnerships; the most successful partnerships are equitable. According to the Clinical and Translational Science Awards Consortium, successful partnerships between communities and health care delivery systems set specific purposes and goals; build trust and establish relationships through working with formal and informal community leadership; encourage community self-determination; respect diversity and recognize cultural influences; provide communities with resources to assist with analysis, decision making, and action; and make long-term commitments regarding technical assistance [11].

In a survey of 237 partnerships across nearly every state, ReThink Health was able to summarize key considerations for funders, policy makers, and others working in ACH-like models. The authors recommend considering developmental phases when crafting and delivering initiatives, engaging in learning to understand trends in the partnership’s development, supporting long-term strategic planning, considering the use of grant funding as a bridge to other financial structures, and emphasizing infrastructure to encourage long-term success in multisector partnerships. Through acknowledging the developmental nature of partnerships and cross-sector collaborations, emphasis is placed not just on improving results within existing systems, but also on “transforming the structure of the health ecosystem itself” [8].

Importantly, community engagement within the ACH model includes consumer engagement. Most models indicate the necessity of consumer input in a decision-making capacity within a governing or advisory board. Interventions grounded in consumer engagement suggest that it is important, albeit sometimes challenging, to engage consumers and consumer advocates in decision-making capacities. Some notable challenges include ensuring that consumers have an equal voice, providing consumers with the tools to understand conversations within the governance board that contain technical language, and preventing consumer burnout from high expectations of participation [12]. In the Aligning Forces for Quality initiative, funded by the Robert Wood Johnson Foundation, communities made provider quality information available to consumers, while also implementing interventions to help providers improve their quality of care and help them engage consumers in ways that help consumers make informed health care decisions [12]. The literature suggests that it is not enough to make health information and data available to consumers; the information must also be easily understood by consumers [12].

States, private organizations, and other ACH funders often allow ACHs to have the autonomy to determine their own governance structure, with some fundamental guidelines. Often, governance structures must be planned as part of a request for proposals before a community receives funding [2]. Funding entities often include provisions mandating governance structures to reflect multisector engagement [13,14]. Leadership teams, or governing bodies, are established, with representation at the individual and organizational level from ACH partners, to develop a process for collaborative decision making regarding the intervention, evaluation, financial obligations, and conflict management [2]. To build a sound governance structure, the California Accountable Communities for Health Initiative (CACHI) indicate the following key conditions: “Effective decision making; accountability to the community; representation of stakeholders’ interest; proper fiduciary, fiscal, and social responsibilities; and control over funding and staff” [15]

It is also important for the participating organizations to cultivate trust and create a common vocabulary. Regular meetings among stakeholders strengthen relationships and build trust within collective impact and other initiatives [7].

The most successful cross-sector partnerships engage one entity, sometimes the fiduciary agent, as a “backbone organization” (also referred to as the integrator, bridge organization [13], anchor institution, or convener) [16]. Often, the backbone organization is a health department or health care delivery system; however, it is possible for a backbone organization to be a community-based organization, nonprofit, or other participant in the ACH [2]. A backbone organization’s key support activities include guiding vision and strategy, supporting aligned activities, sharing measurement practices, building public will, advancing policy, and mobilizing funding [17]. Duties of the backbone organization also may include completing community health needs assessments, developing priorities based on those assessments and other evidence (with input from the rest of the governing board), and ensuring the implementation and evaluation of interventions related to priorities [18]. Joint improvements and collaboration through a backbone organization have been linked to broader engagement of community-based organizations, cohesive development of a shared vision and goals, and overall improvements in health outcomes [2,18].

The backbone organization is responsible for convening and integrating the multisector partners [19]. Multisector partners should convene to establish a shared vision, goals, and an agenda, with all partners in the ACH coming to a consensus on “mission, vision, goals, objectives, and appropriate intervention strategy” [18]. This kind of cross-sector alignment and active engagement of stakeholders may address community health and social needs in a “mutually reinforcing portfolio of interventions” [20], which reaches across sectors to, among other things, deliver high-value health care, reinvest savings, enable healthy behaviors, and expand socioeconomic opportunities. There is some evidence that a mutually reinforcing portfolio of interventions—such as combined investments in health care delivery systems, public health, and community-based initiatives—maximizes health and economic outcomes [21].

Interventions and Return on Investment

Often, public health programs target preventable behavioral risk factors, including smoking, problematic diet, and lack of physical activity [9]. Research suggests that through addressing behavioral risk factors, many inequities in chronic disease that are related to race and geographic disparities can be mitigated, especially in prevention or management of type 2 diabetes and cardiovascular disease [2]. Evidence shows that, in addition to addressing behavioral risk factors, addressing community and individual social needs—including education, housing, food security, and income and employment—can reduce morbidity and mortality of preventable negative health outcomes [22]. Accountable communities for health embrace the need to address health risk factors that exist outside the walls of the clinic. Often, ACHs incorporate a wide spectrum of interventions into their programs, including those that address immediate physical and behavioral health needs and those that involve long-term work in health-related social needs and equity [23]. The interventions are fostered through cross-community and cross-sector networks, with input regarding local health issues coming from community members and relevant key stakeholders [14].

There is a growing expectation on the part of policy makers that investments of any kind show a return on investment (ROI). Investments in population health often require a long-term perspective, with gains in health status accruing over time [9]. This has been one of the biggest challenges for ACHs, as many federal grant programs require progress to be shown in three years [22]. This reflects a debate regarding focus: Should we look to intervene among high-risk, high-cost individuals with a rapid ROI, or should we work to intervene early to prevent someone from becoming high risk, which involves a removed but possibly larger ROI? For example, early childhood interventions have been shown to be effective in improving long-term health outcomes while being cost-effective. However, strategies prioritizing early childhood interventions often receive pushback for their inability to show cost-effectiveness in the short term [25]. Trust for America’s Health breaks down the return on investment for various early childhood interventions, finding a range from a $1.46 return for every $1 invested for insurers in theCommunity Asthma Initiative, to a $25.92 return for every $1 invested in theGood Behavior Game[26]. The Altarum Institute made various estimations of the economic benefits of greater racial equity in Michigan, including a $39,000 lifetime economic value for an “at risk child” achieving school readiness, a 25 percent reduction in spending on state Medicaid and public assistance programs through erasing racial disparity in income, and lower premature death rates [27].

Some public health interventions are able to produce a short-term return on investment. Interventions addressing root causes of disease through social determinant work have demonstrated measurable returns in decreases in emergency department utilization and hospital admissions. For example, at Hennepin Health in Minnesota, the State Innovation Model program provides grant support to link individuals who have been recently released from the county jail or the Adult Corrections Facility to transitional housing and employment supports. Upon analyzing the cohort of Hennepin Health participants, the results showed that between 2012 and 2013, there was a 9.1 percent decrease in emergency department utilization and 3 percent decrease in hospital admissions among participants [26]. In an accountable care community in Summit County, Ohio, a diabetes management intervention that increased participant access to healthy foods and promoted healthy behaviors led to a 10 to 25 percent reduction in per-member per-month costs among participating diabetic members [27].

There is no single prescriptive intervention implemented by ACHs on a large or national scale. Rather, successful ACHs embrace their specific community assets and needs and target interventions to goals that are within reach. Interventions and strategies are created through a shared vision between community and participating partners. Leverage created by coordinated community efforts can improve ACH influence of local policy [29]. Policy-based interventions focusing on social determinants of health—including interventions targeting early childhood development, urban planning, housing, income enhancements, and nutrition—have demonstrated effectiveness at improving long-term health outcomes for disadvantaged neighborhoods [26].

A common concern surrounding the implementation of an ACH intervention is related to community capacity [28]. Resources, not surprisingly, vary across and within communities. Therefore, funders of interventions often bolster capacity-building initiatives. Some interventions employ the use of cross-site learning communities, a technical assistance team, and investments in leadership training. Specialized expertise, rather than generic support, is important when promoting community capacity building [29].

Often, grants are awarded to ACHs in phases: focusing first on capacity building (including creating the coalition and planning an intervention strategy), followed by actual implementation of the intervention. Funding may also be awarded on a phased-in basis dependent on achievement of specific benchmarks or milestones [29]. To frame an intervention and its processes, iterations, and milestones, some communities employ a theory of change model. Some funders may require theories of change, although many communities create them to illustrate the assumptions, general timelines, goals, and expected outcomes of an intervention. Theories of change are high-level logic models that consider the timetables, resources, and investments needed to guarantee an intervention’s success [30]. In a theory of change model, a physical diagram is created to outline ways in which specific inputs (such as funding, existing infrastructure, personnel) or actions (e.g., “setting the table” for multisector dialogue, initiating an intervention) are related to anticipated outcomes (e.g., improved community health). The relationships among inputs, actions, and outcomes are based in time. As the intervention gets underway, an effective theory of change may provide the framework for the evaluation of the intervention [30].

Data and Evaluation

Prioritizing population health demands cross-sector planning, implementation, and evaluation. This includes the necessity to exchange health and social needs information across sectors where relevant. To characterize the scope and scale of community needs, partners of community-oriented interventions may find it useful to link disparate data sources, such as those from the health care delivery system, social services, and others. Coordinated data is an important first step in understanding the magnitude of health needs and identifying how a community can design targeted interventions [31]. However, data exchange is associated with practical and legal challenges [32]. Data sharing across sectors can be difficult, especially when considering patient privacy protections. The Health Insurance Portability and Accountability Act (HIPAA) and Title 42 of the Code of Federal Regulations Part 2 have often been cited by health care providers as barriers to exchanging a patient’s health information and to realizing the full potential of care coordination [33,34]. However, some ACHs have persevered, creating data warehouses that gather information from multiple, competing health care and social service providers. Hennepin Health has engaged in a HIPAA business associate agreement (the contract a business associate must sign with the covered entity to ensure compliance and assume liabilities associated with violation of the HIPAA Privacy Rule and HIPAA Security Rule [57]). Patients are asked to consent to the sharing of their health information when applying for Medicaid benefits, when receiving medical care, and when receiving social services. It is the direct obtainment of patient consent that allows Hennepin Health to share data freely among partners [35]. The data are then analyzed and used to evaluate the intervention [23,36]. Creating data-sharing agreements among intervention partners, such as a memorandum of understanding, may be a feasible way to share information and protect privacy, while adhering to regulations across sectors. The creation of a data-sharing agreement is often the responsibility of the backbone organization [23].

The Center for Healthcare Organizational and Innovation Research (CHOIR) produced a toolkit designed to give advice on best practices for communities engaged in cross-sector data sharing [37]. The toolkit specifically addresses data sharing within ACHs and stresses a continuum from beginner to advanced. CHOIR describes seven parameters for assessing maturity across this data-sharing continuum. The seven parameters include purpose/aim, relationships/buy-in, funding, governance and privacy, data and data sharing, technical infrastructure, and analytic infrastructure. Within each parameter, CHOIR lists common barriers reported by communities and strategies to overcome those barriers. CHOIR suggests that communities interested in cross-sector data sharing build a common foundation among stakeholders by identifying a purpose or goal surrounding health concerns in the community; building relationships among stakeholders; securing funding; establishing parameters for data governance, specifically data-use agreements; considering the type and content of data needed to answer common goals; and obtaining or building the needed technical and analytical infrastructure [37].

The literature suggests that providers have little guidance for finding ways to add social determinants of health into electronic health records (EHRs). Some providers capture social and behavioral determinants of health in an EHR within a patient’s social history narrative [4]. Population health may be improved through inclusion of social-determinant-related questions into the EHR, which permits greater precision in diagnoses, facilitates shared decision making (among clinical staff, patients, and social workers), promotes prevention (through the identification of social determinant risk factors), promotes intra-ACH referrals (such as from the health care delivery system to social services), and enhances internal review of community-related health risk factors and needs [4]. CMS developed a screening tool for their Accountable Health Communities Model to evaluate the impact of different entities in addressing health-related social needs to improve health. The 10-question screening tool addresses housing instability, food insecurity, transportation needs, utility needs, and interpersonal safety [37]. In 2016, HealthPartners released summary measures comprising three components: current health, sustainability of health, and well-being. These measures may be used by ACHs and ACH-like initiatives to assess conditions that create the greatest impact on the health and well-being of their consumers, thereby guiding their community-directed initiatives [39].

In addition to sharing data about health information, it is also necessary to share data among partners regarding status of intervention outcomes. For example, one intervention created a web-based results database with data from each participating site. With all sectors updating their sites quarterly, each member organization of the intervention was able to stay engaged by setting targets and assessing progress. The web-based tool encouraged site autonomy, and each site had the ability to generate impact reports targeting a specific result area, indicator, strategy, or performance measure [40]. Impact reports present an evidence-based picture of the effects a partnership’s efforts have in relation to the direct and indirect costs they incur [16]. Appropriate collection, use, and sharing of data becomes crucial when considering an intervention’s evaluation.

Upon creating an evaluation of ACHs (or any other interventions that address social needs through the context of health care delivery services), evaluators may experience barriers such as the need to address many steps along the path of screening for social needs, the need to address potential confounders (such as quality of social services provided and resolution of problem), and the need to allow for adequate time before evaluating ultimate outcomes [41]. To evaluate the content and dose of social needs interventions, evaluators may track patient referrals, successful connections between consumers and social services, and resolution of social need [41].

In 2014, the Institute of Medicine (now the National Academy of Medicine) published recommendations for measures of evaluating a patient’s social determinant needs, which were drawn from validated assessments [42]. These kinds of measures are essential when assessing the cost-effectiveness of an ACH intervention. A cost per quality-adjusted-life-year (QALY) approach for assessing cost-effectiveness may be difficult to apply to upstream interventions [43]. Upstream interventions (for example, an intervention centered upon kindergarten readiness [44]) are complex, with effects that are often not seen for many years and manifest across sectors [43]. Efforts to analyze ACH and population-related efforts often evaluate effects of the intervention across sectors, including unintended benefits and consequences. For example, an effort to evaluate health impacts of a housing program might also assess impacts in residential stability, social networks, access to health and social services, and exposures to new stressors [24].

In Vital Signs: Core Metrics for Health and Health Care Progress, the Institute of Medicine identified a core measure set designed to apply across different levels of the health care delivery system. The measures address quality of care, costs of care, and individual engagement in health and health care. However, the authors recognize that data is currently limited in addressing multisector performance on the addressed issues. The core measure focus areas are life expectancy, well-being, obesity, addictive behavior, unintended pregnancy, healthy communities, preventive services, care access, patient safety, evidence-based care, person-centered care, personal spending burden, population spending burden, individual engagement, and community engagement [45]. Some of the aforementioned measures are already collected by health care delivery systems; however, many may require the adoption of survey tools with data collection reliant on consumer consent.

To evaluate population health interventions, it may be effective to categorize measures by level of multisector engagement. For example, one study created a typology for multisector engagement in population health activities through three sets of measures: the scope of the population health activities contributed by each type of organization (for example, business-related, community, or educational organizations; health care delivery systems; or payers), the density of connections that exist among organizations partaking in the community health effort, and the extent to which organizations play a coordinating role within the network [9]. The Agency for Healthcare Research and Quality has created the clinical­–community relations measurement framework, which provides a structure for identifying, categorizing, and understanding basic components of effective relationships between clinical services and community resources. The framework’s measurement domains can provide the basis for empirical assessment of structure, processes, and outcomes of relationships at the community level [46]. Across the literature, there is an emphasis on defining and evaluating the capacity of organizations participating in cross-sector collaborations [9,39,46].

During the process of evaluation, evaluators for Making Connections—a multisite, multiyear intervention seeking to improve childhood outcomes through cross-generation and cross-sector improvements and alignment [41]—cultivated high-level research questions to effectively communicate program goals and outcomes. The research questions included ones relevant to overall community conditions and key indicators; explicit changes on an individual level or that of a subgroup; changes in community capacity (including systems of support and opportunity); pursued strategies (e.g., a process-level evaluation); and the sustainability of improved capacities, upward trends, or positive outcomes. Effective evaluation provides a critical bridge to public policy interventions [40]. To influence public policy, community-based initiatives may seek to determine which parts of an intervention are generalizable [30].

The Blue Sky Consulting Group identified six key steps in the optimal approach for evaluating ACH initiatives. Those steps include development of a logic model identifying essential components to achieve desired outcomes, use of specific evidence-based measures that are both quantitative and qualitative, comparison of actual implementation experience to the expectations as presented in the logic model, assessment of multilevel contextual factors that influence outcomes and implementation experience, continual quality improvement through technical assistance to ACHs in understanding and using data, and finally identification of emerging principles and lessons learned. This optimal approach is flexible enough to be generalized across ACH designs [47].

Financing

Finding entities willing to invest or provide sustainable funding streams can prove difficult for ACHs. The collaborations need start-up funds—support for the initial intervention or implementation stage—and sustainable funding once the approach has been proven effective. Funders may be reluctant to pay for infrastructure and prefer investment in short-term solutions. However, ACHs and other collective impact models challenge funders to move from the position of a one-time funding organization and into the long-term process of enacting social change [7]. Once established, the financing streams of ACHs are diverse. Some are funded through State Innovation Model grants [48]; some, through private philanthropic or nonprofit organizations. Others are coordinated efforts between an ACO and other community programs, while some funding streams come as a result of a hospital’s community benefit requirement (implemented under the ACA) [49]. Other initiatives find unique ways to combine various funding streams within the health care delivery system and community [8,14,50]. Additional financing structures, in order of relative dependability, include grants, contracts and prizes, in-kind agreements, loans and investments, dues, sharing agreements, taxes, and credits [51]. Some states envision circumstances in which ACHs will be most financially viable and sustainable through integration with delivery and payment system reform, and funded by both private and public payers [2,23]. The wide variety of available funding streams creates the opportunity for braiding or blending of multiple funding sources when appropriate. However, this patchwork of funding streams comes with strings attached—often in the form of distinct eligibility criteria and implementation requirements (sometimes including requirements for the organizations receiving the grant and the population eligible to enroll in the program) [9]. It may be difficult for ACHs to manage various funding streams, especially in cases involving start-and-stop funding periods. With each distinct funding source, complexity increases. An ACH should designate a financial manager, or funding hub, with the capacity to identify, apply for, and coordinate funding streams, thereby ensuring sustainability. Occasionally, the funding hub may also serve as the backbone organization; however, selection of an appropriate entity depends on each community’s assets, needs, and capacity [52].

Grants might fund the entire ACH operation, but they usually aid with specific activities and infrastructure, including technical assistance, health information technology development, and general start-up grants. Start-up activities funded by an initial grant may include staffing, coordination of community referral systems, and development of plans for data sharing [2]. According to the John Snow Research and Training Institute, there are various pathways to financial sustainability for an ACH. First, ACHs must secure infrastructure funding for programmatic and administrative functions. This start-up funding often comes from philanthropy, hospital community benefit, and government grants. Later, the ACH may explore financial engagement from private and public payers, such as through investments by private insurance or Medicaid [53].

Financial involvement can be incentivized through pooled savings associated with health improvements and reduced health care utilization [53], or improvements in other sectors. Many ACHs recognize the need for a collaborative, cross-sector risk-sharing arrangement, since health may be a side benefit of policy programs across other sectors [51], just as other sectors may generate savings from health-based programs. In fact, cross-sector partnerships and financial agreements may foster willingness by state legislatures to approve funding requests [49]. Successful risk-sharing arrangements align financial incentives with community- and patient-level outcomes, and are agreed upon within the governance structure. For example, an ACH might coordinate social services, public health, and local safety net health providers to engage in a financial partnership [37]. In many cases, the backbone organization plays a leading role in developing risk-sharing arrangements.

The Wellness Trust model provides an example of how to “capture” savings from ACH-supported interventions and catalyze joint investment [53]. As envisioned in the CACHI program, this trust would be jointly governed by community partners to reinvest savings in new or upstream interventions and could also be a vehicle for joint investment by multiple partners [20,54]. This expands on the Prevention and Wellness Trust Fund concept, originally passed in Massachusetts, which was supported by fees charged to health insurers and acute care hospitals to support community-based prevention grants in the state [55].

The National Governors Association (NGA) has reported on opportunities for coordinated efforts between communities and health care delivery systems. The NGA acknowledges that whether or not federal funding is available for ACH-like models, states have the autonomy to encourage community-based interventions as a means to increase the effectiveness of their Medicaid and Children’s Health Insurance Programs (CHIP). However, the NGA also notes that state governments may find it difficult to promote long-term funding of such measures, unless they are incorporated into tax policy, incentives for public-private partnerships, or other innovations [56]. The NGA recommends various financial strategies to incentivize creation of community–health care delivery system partnerships, including adopting payment policies to reimburse community health workers (for provision of services under Medicaid and CHIP), adding community coordination as a specification for direct contracting arrangements with provider delivery systems, and encouraging the funding of community care team programs by nonprofit entities, private foundations, charitable organizations, and counties through grant making [2].

Conclusion

We are in the early days of accountable health initiatives, focusing on establishing the principle of accountability for a community’s health and applying it to the multiple sectors that contribute to health. Within the health sector, ACHs are expanding the concept of accountable care (for individuals or groups of individuals) to accountable health (for a community). ACHs build on experience with multisector, collective impact, and community engagement models within and beyond health [58].

Accountable health initiatives use a variety of approaches in terms of their scale and focus. There is some debate about what measures are appropriate for accountable health—regarding cost-effectiveness, return on investment, and time frame. Best practices for building the data systems that support accountable health are also in the early stages, and long-term financial sustainability for accountable health initiatives has not yet been defined. Given the variety of approaches that fall within the rubric of accountable health, common approaches to evaluation have also not been defined.

Despite all these uncertainties, there is a common set of principles driving these initiatives relating to the value of improving population and community health through (1) growing investments by public and private funders for pioneering accountable health initiatives [52]; (2) focused dialogue among these investors through the Funders Forum on Accountable Health, to assure that there is cross-initiative learning and coordination; and (3) ongoing movement building through entities such as the National Academies of Sciences, Engineering, and Medicine’s Roundtable on Population Health Improvement. Accountable health initiatives may be early in their development, but they are promising in the drive toward achieving the Triple Aim.

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National Academy of Sciences, Engineering, and Medicine. 2017. Building sustainable financing structures for population health: Insights from non-health sectors. Washington, DC: The National Academies Press. https://www.nap.edu/download/24760 (accessed September 5, 2017).

Kohli, J., and A. De Biasi. 2017. Supporting healthy communities: How rethinking the funding approach can break down silos and promote health and health equity. Washington, DC: Deloitte University Press.

National Governors Association. 2012. Strategies for states to encourage and fund community care teams. Washington, DC. https://www.nga.org/cms/home/nga-center-for-best-practices/center-publications/page-health-publications/col2-content/main-content-list/strategies-for-states-to-encoura.html (accessed May 1, 2017).

On November 9, 2017, theNational Academy of Medicine(NAM) will host a first-of-its-kind pop-up art exhibition that explores health equity and gives voice to communities around the nation. Health equity means that everyone has the same shot at living a healthy life and requires attention to “social determinants of health” – like access to healthy food, good jobs, and safe neighborhoods. Health equity is the focus of a 5-year, $5 millionCulture of Healthprogram at the NAM, funded by the Robert Wood Johnson Foundation.

This past summer, the NAM put out a nationwide call for artists to submit artwork of all kinds that illustrates how communities understand health inequity and the solutions that promise a brighter, healthier future. Artists were asked to answer: What does health equity look, feel, and sound like to you?

Artwork for the pop-up exhibit was selected by a panel of reviewers drawn from the Culture of Health program advisory group. Thirty pieces of art were selected for the pop-up exhibition based on the insight each piece brought to the subject of health equity, as well as artistic impact. Pieces include visual and nonvisual art, such as music, creative writing, paintings, drawings, and spoken word. The following artists are featured in the show:

“These talented local artists have added important new insights to our work on health equity,” said Laura DeStefano, NAM director of communications. “The involvement of communities in defining their own goals for health and well-being is essential for progress. We hope the ‘Visualize Health Equity’ art show will get more people talking about health equity and working together on solutions.”

In addition to the pop-up exhibition, over 100 submissions have been selected to appear in a permanent online gallery, launching November 9. This website will be an interactive hub that aims to promote bidirectional dialogue on issues related to health equity. To learn more, please visit nam.edu/VisualizeHealthEquity.

To register to attend the pop-up exhibition on November 9 in Washington, DC, please click here.

Introduction

We are in the midst of a transformation of our health care system. The shift from volume to value and the corresponding changes in payment models necessitate an evolution in focus from the acute medical needs of an individual to a more holistic view of improving the health of the population. This more holistic strategy includes a recognition of the importance of the environmental, social, and behavioral determinants of health and a paradigm shift with an implicit understanding that health is a function of a health care system embedded in an interconnected community. Health happens wherever families are—at home, in schools, in child care, in medical homes, and digitally at any location in the community. Building upon a variety of community-based models funded by the federal government, states, and private funders, as well as the Center for Medicare and Medicaid Services’ Accountable Health Communities Model, this paper adapts these models of integrated care to seamlessly address the medical, social, and developmental needs of children and families, with a focus on shared accountability across sectors as well as financial sustainability.

Why Focus on Children and Families?

Research has shown that the foundations of health take root in the earliest years (including the health of the mother). Young children are particularly sensitive to social determinants [1]. Additionally, adverse childhood experiences occurring in early childhood can have lifelong consequences, affecting physical and mental well-being. For example, traumatic experiences such as persistent poverty can disturb neurobiological systems that guide physiological and behavioral responses to stress and permanently increase the risks of disease [2]. “Developmental, behavioral, educational, and family problems in childhood can have both lifelong and intergenerational effects. Identifying and addressing these concerns early in life are essential for a healthier population and a more productive workforce” [3].

An Accountable Community for Health for Children and Families could significantly improve the health trajectories of children and families and promote health equity through financially sustainable, place-based, multisector partnerships.

A Vision for the Future

Prevention, early intervention, and strengthening the family unit are at the core of optimizing child health and well-being. Yet the current system is not adequately oriented toward achieving these aims in a financially sustainable manner. All too often, health care approaches focus on addressing the needs of high-cost adults rather than on the unique health and developmental needs of children. What could the future look like? It would include a system in which the following is the norm in a growing number of communities across America:

A pregnant teen seeks health care services at an urgent care clinic and is screened for social determinants of health. She is referred to an ob/gyn for regular prenatal care. When her screening indicates that she is housing insecure, she is connected, via a community hub, with community resources to address this need, thereby avoiding the toxic stress she and her child would experience because of unstable housing. Once her child is born, her pediatric provider connects her with free parenting classes, a service offered as part of its risk-based contract with a payer (in which the provider is rewarded for keeping patients healthy and reducing unnecessary health care utilization).

A community database with GIS mapping capabilities reveals a cluster of problems caused by lead in a housing complex. The health department contacts all families living in the unit to get their children tested for lead exposure and works with the landlord to address abatement, thereby preventing future exposures. The health department also contacts the pediatricians/medical homes of affected children for follow-up. The abatement in the complex is covered through Children’s Health Insurance Program (CHIP) administrative dollars through a health services initiative approved by the state. The medical services are covered through Medicaid.

A child scores below the normal range on a reading-readiness screener administered at her early care and education (ECE) center. The center contacts her pediatrician’s office, which refers the family to a community-based early literacy program, whose services are included as part of a risk-based contract. A nurse at the pediatrician’s office and the ECE provider advise the parents about what they can do at home and suggest free tools.

Asthma is the leading cause of absenteeism in a school system. The school nurse believes asthma can be better controlled at school and that triggers in the home need to be addressed. She reaches out to the pediatric health system to collaborate, and they also begin working with the health department. With parent permission, the school nurse is granted access to participating children’s electronic health records so she can ensure she is following the child’s latest asthma action plan. A community health worker employed by the health system, as part of its value-based contract, visits the homes of children who have had multiple health care visits related to asthma to educate the families about trigger reduction. The health department uses GIS mapping capabilities to identify asthma “hot spots” and collaborates with the housing department and landlords to decrease the number and frequency of asthma triggers in those areas by addressing mold and pest problems, removing carpets, and reducing secondhand smoke exposure by enforcing a ban on smoking in public housing. Additionally, a community coalition works to reduce harmful emissions near the school, thereby amplifying reach and impact on children.

How Can We Build More Coordinated Systems to Optimize Child Health?

After decades of studies, researchers have concluded that social factors (e.g., socioeconomic status, education, housing, transportation, access to food, and so on) have a powerful impact on health [4]. Given the mounting evidence regarding the importance of the early years in shaping an individual’s long-term health trajectory, it is critical to address social determinants early on. Leading thinkers have posited that forging structured collaborations among multisector community partners who share goals and resources is critical to “moving health care upstream.” Examples of proposed models include building a transformed 3.0 health system that optimizes health [5,6,7], funding integrators [8], anchor institutions/backbone organizations [9,10], and supporting accountable health communities [11,12], in which partners can collectively address social factors impacting health.

Various federal initiatives have taken important steps to improve community health (e.g., Promise Neighborhoods, various Centers for Disease Control and Prevention programs, and numerous community prevention programs funded by foundations). We are beginning to see the next generation of innovative population health approaches that tie more directly to the health care system to promote sustainability—Accountable Health Communities—(i.e., the Center for Medicare and Medicaid Innovation AHC model) and Accountable Communities for Health (ACH) (e.g., the State Innovation Models in Minnesota, Vermont, California, and Washington State). Future initiatives building on this work should focus on children and families, measure success across sectors, and forge stronger clinic-to community connections for geographically defined populations, all fueled by value-based payment and other innovative, cross-sector sustainable financing mechanisms.

What Is an Accountable Community for Health for Children and Families

An ACH is a structured collaboration among health care, public health, and other partners (e.g., schools, community-based human service agencies) to improve health, safety, and equity within a defined geographic area through comprehensive, coordinated strategies [12]. The ultimate goal of an ACH for Children and Families is thriving children and families—accomplished by a focus on optimizing health, improving quality, and reducing the total cost of care for a population over time. The model would seek to optimize health trajectories of children (prenatal to age 26) and their primary caregivers in a geographic area over time, in addition to improving care and reducing costs for high-cost users. The model necessitates a community coming together around shared health goals and a business case in which they are all held financially accountable and jointly responsible for achieving shared goals and metrics that spill over into different sectors, with an integrator serving as the glue that binds the initiative. The core of this model is identifying and addressing health-related social needs for the child and family (e.g., housing, food security, education, economic stability, and so on), creating stronger connections among key sectors to support a more efficient “community care coordination system,” where the needs that are identified are addressed through existing community resources, and filling in gaps where there is no provider or service to address needs. The work that lies ahead is tailoring and applying an ACH model to children and families in a geographic area, with a focus on screening, prevention, and early intervention to optimize health and development across the trajectory.

Guiding Principles for an ACH for Children and Families Model

Everyone should have an equal opportunity for health according to his or her needs.

Improving child health necessitates a focus on the family—from addressing basic needs (housing, food, and so on) to strengthening parenting competencies to amplifying family representation in decision making. It also requires a focus on identifying and addressing developmental delays and needs through appropriate intervention across the life course.

There is no wrong door through which to improve child and family health; all community partners and members have a role to play.

Optimizing child health goes beyond health care. It means attending to the whole child’s health, development, and well-being and engaging the sectors where children spend time to develop shared goals and partnerships that result in meaningful collaboration.

Onerous requirements and rigidity stifle innovation; initiatives designed to advance accountable health models should foster conditions for local innovation (including payment models), allow flexibility, and reduce burdensome and duplicative reporting requirements at the local level.

Older adults are a costlier, sicker population than children, and therefore achieving short-term wins and cost savings is a more reasonable proposition for the older adult population. Models designed to optimize child health should have a return on investment (ROI) time frame of at least 7 to 10 years. In addition, it may be prudent to design an approach focused on families that may balance a long-term ROI for the child and a short-term ROI for the adult, especially in the case of a long-term, high-cost chronic disease or condition affecting the whole family.

To move the needle on health over time, a mix of public and private funds is necessary and can inspire key community stakeholders to create shared ownership for a common community destination and then become jointly accountable for arriving at that destination.

Core Elements of an ACH for Children and Families

The following recommended elements represent a mix of features that are included in a paper describing the key roles of an integrator [13], existing ACH models and descriptions (e.g., the California Accountable Communities for Health Initiative [14], the Prevention Institute’s paper [12]) or Accountable Health Communities models (e.g., the Innovation Center), in addition to elements added as a result of a November 1, 2016, Nemours–Aspen Institute convening and subsequent calls.

Shared vision and addressing gaps: Partners would agree upon a shared vision and goals to optimize health for children and families across the trajectory and to reduce health disparities, including a plan for addressing unmet needs.

Integrator/backbone/bridge organization to connect Multisector Partners: Communities would develop or build upon formal collaborations among health care, social services, community development financial institutions, child and family–serving organizations, and community members and families dedicated to achieving the shared goals. An agreed-upon entity (integrator) would serve a convening role and work intentionally and systematically across sectors to improve health and well-being for a geographically based target population. The integrator would identify entities with which it would contract to provide a portfolio of interventions, as well as invest to build community capacity to provide services that are not currently available but are needed (based on the results of the community needs assessment and empirical evidence of interventions effective at meeting those needs). Additionally, the integrator would play a key role in developing and managing a cross-sector financial sustainability mechanism to pool funds across sectors and reinvest the shared savings in future prevention initiatives. Examples of lead entities could be community-based organizations, health care practices, hospitals and health systems, educational institutions, local governments, health departments), tribal organizations, and for-profit or nonprofit organizations, including payers.

Trusted community leadership and governance: Communities would identify trusted champions and develop a governance structure that describes the decision-making process and articulates key roles and responsibilities. Families would play key roles in the governance structures. Communities would be encouraged to develop innovative ways to reduce barriers to meaningful community engagement (e.g., leveraging private dollars to cover the cost of child care or transportation for parents while they attend ACH planning meetings). Over time, communities should strive to maximize equitable participation and community voice in governance, ensuring that individuals from all socioeconomic statuses and backgrounds have meaningful opportunities to contribute as equal partners to the development and functioning of the model.

Two-generation approaches: Communities would develop strategies aimed at improving the health of children (prenatal to age 26) and their primary caregivers, with special attention paid to promoting health equity and addressing health disparities. This includes addressing basic needs (housing, food, and so on for families) as well as improving parenting skills and competencies through interventions in the community, home, and/or health care setting; family engagement and family representation in decision-making and governance structures; and specific strategies designed to meet the needs of and provide supports for pregnant women, with a goal of building safe, stable, and nurturing home environments for every family.

Population and patient-level metrics and outcomes to achieve a shared community destination: Building on the IOM report Vital Signs: Core Metrics for Health and Health Care Progress and evolving work to develop pediatric core metrics, communities would select a set of short-term, intermediate metrics with long-term implications, as well as long-term metrics with spillover effects in various sectors, and would be held jointly accountable for achieving progress at the patient and population level within a geographic area, including a total-cost-of-care metric. This would include a mix of patient- and population-level clinical outcomes and nonclinical outcomes that can be achieved across various time frames (e.g., short term: reductions in unnecessary health care utilization, school days missed, improved food and housing security; intermediate term: proportion of children ready for kindergarten, reading by grade level; and long term: diminishing needs for special education with effective early intervention, changes in high school graduation rates, and reductions in health care costs). While achieving progress on long-term metrics would be an overarching goal, communities should prioritize early wins in the short term.

Data analytics and evaluation: A Technical Assistance (TA) Center (funded by either a foundation or a government agency) would help communities develop approaches and agreements for collecting, analyzing, and sharing financial, community, and population-level data across a variety of providers and organizations needed to advance common goals. In compliance with existing laws governing protected health information and student education records (e.g., the Health Insurance Portability and Accountability Act, Family Education Rights and Privacy Act) and other relevant laws, sharing of data publicly and with community partners would occur and would be used to drive change through empirically informed decision aids. The TA Center would assist in sharing best practices, guidelines, and memoranda of understanding currently used to promote data sharing, identify barriers, and develop proposed solutions, as needed. Additionally, independent evaluators would assess progress toward achieving the goals set forth. If communities had a strong rationale for altering their metrics during the course of the award, flexibility would be granted.

Community Care Coordination System: A community care coordination system helps ensure that individuals are referred to and obtain the medical, behavioral, and social services they need across sectors without duplication, including ensuring that the referring provider is notified when services are provided.

Key Portfolio of Interventions: Communities would perform (or use an existing) needs assessment/community resource inventory; identify, refer, and treat participants through screening (including using developmental and social determinants screening tools) and early intervention strategies based on risk stratification; develop and implement prevention strategies; and incorporate health care approaches to reduce cost and utilization. Inclusion of family-centered medical homes would be required. Communities would develop and implement a portfolio of interventions tailored to meet the community’s needs, based on the best available evidence, ensuring that the needs of the most vulnerable are addressed and that a full range of interventions, from clinical to policy, systems, and environmental changes are considered. Sustaining effective interventions would be critical. As such, communities would (a) develop a glide path to value-based payment with one or more payers that sustains the most effective interventions, thereby aligning incentives among health care providers, payers, and community health goals; and (b) match specific interventions to other appropriate financing vehicles, drawing from the full range of innovative financing vehicles that are emerging. (See number 10.)

Value-based payment: A glide path to value-based payment with one or more payers, managed care organizations, and providers would be required given that all parties would have aligned incentives related to cost, quality, and health outcomes. It could include clinical payment (rooted in primary care) as well as a community component, which could include incentive payments for community partners. Communities should have flexibility to experiment with different payment models. Communities would be required to link the data they collect, the metrics they are seeking to achieve, and the value-based payment model that rewards progress toward achieving the outcomes they set forth.

Financial sustainability: Communities would develop and implement a sustainable plan for securing resources to support the goals, priorities, and strategies developed by the ACH. The integrator would take the lead in setting up appropriate financial sustainability mechanisms. Examples of structures or mechanisms to be included in the plan are wellness and prevention funds; social impact investments; support from private funders (philanthropy, business and industry, and so on); support from insurance companies, managed care organizations, and health care providers (including working with community partners to reduce unnecessary health care spending and utilization); multisector, blended funding (e.g., through current and future Medicaid waiver programs); and community development banks. The goal would be the creation of shared savings and incentives across sectors to promote joint financial accountability in pursuit of the community’s overarching goals and metrics.

Learning Systems and Communications: Learning and communication would occur across sites and within sites. Across sites, funded communities would be part of a learning and Technical Assistance infrastructure, including (as described above) a dedicated organization focused on (a) providing TA to awardees; (b) developing learning collaboratives to share insights and lessons, and work through challenges in real time; and (c) developing a mechanism to capture feedback from awardees (as well as participants in other related initiatives) regarding barriers they are facing to assist in creating flexibility and cutting through red tape to overcome the barriers. Within sites, communities would develop a system of ongoing and intentional communication and feedback among partners and community residents. The voice of the family would be amplified through communications’ structures. The feedback loop created would inform how resources are allocated (e.g., when referrals for service are made but there is no community provider that can fill the need) and what federal, state, or local barriers are hindering progress.

Special Considerations for Implementation of an ACH for Children and Families

Included below are practical considerations for communities that are exploring testing an ACH for Children and Families.

Community readiness: Communities should assess where they are in the implementation of the core elements above. For communities that are just beginning to come together, the initial focus should include ensuring that a comprehensive set of partners (see next bullet) are engaged and developing a plan to work together on shared goals and metrics. For other communities that already have these partnerships in place, focal areas might include the development of the community care system and the plan to develop joint financial accountability for shared aims.

Target Population: An ACH for Children and Families is designed to optimize health for all children and families in a geographic area. Some universal interventions will impact the entire population, and risk stratification will also need to occur for targeted interventions. Although the needs of high-utilizers and high-cost populations should be specifically addressed, it will also be important to test whether costs could be averted and outcomes improved by specifically addressing the needs of medium-prevalence and medium-cost users.

Partners: Partners should include those providers with the greatest impact on child health and development. The following are examples of key partners:

Early care and education (preschools, Head Start, child care centers, and so on); schools and school districts; child-serving organizations; housing agencies or nonprofits; food-systems and food-security organizations; transportation and land-use planning agencies or organizations

Return on investment (ROI) time frame: Given the nature of the outcomes ACH for Children and Families models are seeking to achieve, outcomes should be tracked over 7-10 years. Communities should explore analyzing savings across sectors.

Metrics: The metrics for an ACH for Children and Families are likely to differ from those of a “traditional” ACH, though there would be some overlap. Examples of metrics that might be considered are proportion of children ready for kindergarten, school days missed, reading by grade level, number of health and developmental screenings, community resources identified and referred to, food and housing security, proportion of infants born healthy and to prepared parents, and proportion of adolescents who use alcohol or tobacco or that develop mental health conditions.

Payment model innovation: Value-based pediatric models are not as prevalent as value-based models for the adult population. Accordingly, communities should work with payers and their states to innovate and experiment with different types of payment models to enhance understanding of what works. This may require more innovation and testing than is the case with adult-focused models.

Integrating an ACH for Children and Families with other ACHs: It will be important to test whether a stand-alone ACH for Children and Families would achieve the scale and eventual cost savings needed for success or whether an ACH for Children and Families should be embedded in a broader ACH (with some shared infrastructure, data sharing, and so on, but distinct payment models and metrics) to achieve financial sustainability. Both models should be tested and studied.

Conclusion

Given the state of the science regarding the importance of early brain development and the “foundations of lifelong health” [2] taking root in the early years, there is a need to continue to explore models of care that explicitly seek to optimize health across the lifespan, starting in the early years. An ACH for Children and Families offers the opportunity to bring together community partners to address the social, developmental, and health needs of the child and family, thereby creating the potential to reduce adverse outcomes and improve a child’s trajectory. Although this model is likely to produce fewer health care cost savings in the short term than a model focused on high-cost adults, over the long term, it offers the potential to improve outcomes and reduce costs across a number of sectors, thereby building a stronger foundation to help sustain the community partnerships, data sharing, and financial sustainability mechanisms inherent in the model. Additionally, embedding an ACH for Children and Families within a broader ACH would afford communities the opportunity to address the needs of a portfolio of populations with a portfolio of interventions, using some shared infrastructure. A reorientation toward upstream prevention, community-based solutions, and value-based care through an ACH for Children and Families would support a paradigm shift and community culture explicitly focused on helping children and families reach their full potential.

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The winners of the fifth annual D.C. Public Health Case Challenge were announced at this year’s National Academy of Medicine Annual Meeting. The challenge aims to promote interdisciplinary, problem-based learning around a public health issue of importance to the local Washington, D.C. community.

Universities in the D.C. area formed teams consisting of five to six members from at least three disciplines. Teams were presented with a case, written by an independent team of students from the participating universities, that provides background information on a local public health problem. Teams were given two weeks to devise a comprehensive intervention, which they presented to an expert panel of judges. Teams were judged on the interdisciplinary nature of their response, feasibility of implementation, creativity, and practicality.

The 2017 Case Challenge topic was “Lead and Adverse Childhood Experiences: Neurological and Behavioral Consequences for Youth in the District of Columbia.” The student teams were asked to develop a solution to this complex problem with a hypothetical $2.5 million budget.

The 2017 Grand Prize winner was Howard University. Team members Mark Lorthe, Nancy Alexis, Nicole McLean, Camille Robinson, Johnothan Smileye, and Tahirah Williams proposed a solution titled “CATCH: Communities Advancing Through Child Health.” Their multi-faceted and multi-level intervention proposed providing staff training and certification opportunities to unlicensed child care providers and supporting parents as an entry point for tackling exposure to both lead and adverse childhood experiences, linking families to legal aid for rental housing lead issues, and hosting summertime events to engage and educate the community.

Three additional prizes were awarded, including two Harrison C. Spencer Interprofessional Prizes.

Practicality Prize: The American University team’s solution, Empower and Ab8, sought to use community health workers and a mobile medical trailer to provide blood lead screening paired with policy advocacy and a partnership with landlords to mitigate and prevent lead exposure among children being raised by single mothers. (Team members: Abhishek Patel, Laurel Booth, Diane Kim, Shyheim Snead, Maile Young)

Interprofessional Prize: The Georgetown University team’s Project Resilience was designed to deploy community health workers and political and legal action to address early childhood exposures to lead while at the same time avoiding family displacement and instability. (Team members: Caroline King, Noah Martin, Prakesha Mathur, Emily Shaffer, Katelyn Shahbazian, Matthew Simmons)

Interprofessional Prize: The George Washington University team’s Brain Project aimed to use a federally qualified health center as the entry point for community ambassadors to help link vulnerable families to community services and in-home coaching, while also working at the policy level for primary prevention. (Team members: Amali Gunawardana, Lauren Hunter Naples, Nehath Sheriff, Heather Walter, Gaby Witte, Jordan Wolfe)

Al McGartland, Director, National Center for Environmental Economics, and Chief Economist, U.S. Environmental Protection Agency; and a member of the National Academies’ Roundtable on Environmental Health Sciences, Research, and Medicine

Deborah Klein Walker, President, Global Alliance for Behavioral Health and Social Justice; and a member of the National Academies’ Forum on Promoting Children’s Cognitive, Affective, and Behavioral Health

Additional information about the D.C. Public Health Case Challenge can be found at here.

The D.C. Public Health Case Challenge is co-sponsored by the National Academy of Medicine’s Kellogg Health of the Public Fund and the National Academies of Sciences, Engineering, and Medicine’s Roundtable on Population Health Improvement, with support from the Global Forum on Innovation in Health Professional Education.

For her leading role in driving awareness and adoption of palliative care services in the United States, the National Academy of Medicine (NAM) today awarded the Gustav O. Lienhard Award for Advancement of Health Care to Diane Meier, professor of geriatrics and palliative medicine, Icahn School of Medicine at Mount Sinai, New York City. The award, which recognizes Meier’s achievements with a medal and $40,000, was presented to her at the National Academy of Medicine’s annual meeting in Washington, D.C.

As a geriatrician, Meier found that modern medicine’s focus on curing disease and prolonging life ignored crucial elements of patients’ and families’ distress, including pain, depression, anxiety, sleeplessness, and other symptoms. First at Mount Sinai, and then through the Center to Advance Palliative Care, Meier defined the components of palliative care and clarified its impact on the well-being of patients and families.

To help promote the advancement of quality palliative care, Meier established the Hertzberg Palliative Care Institute at Mount Sinai, which was a model program to help patients and families navigate the complexity of illness and devise strategies for managing pain and other symptoms. As a clinician she published widely on palliative care in major medical journals, developed guidelines and national quality standards for the field, and educated the general public about the need for palliative care through the media. Her efforts have spurred impressive growth in the nation’s palliative care capacity; there are now over 1,800 programs in the U.S. dedicated to this type of care, and more than 80 percent of people in U.S. hospitals have access to palliative care teams.

“Meier’s tireless work as a researcher and as a clinician has resulted in reducing the pain and emotional distress of countless individuals and their families struggling with serious illness,” said National Academy of Medicine President Victor J. Dzau.

Meier is the 32nd recipient of the Lienhard Award. Given annually, the award recognizes outstanding national achievement in improving personal health care in the United States. Nominees are eligible for consideration without regard to education or profession, and award recipients are selected by a committee of experts convened by the Academy. This year’s selection committee was chaired by Regina Benjamin, NOLA.com/Times Picayune Endowed Chair in Public Health Sciences at Xavier University of Louisiana.

The Lienhard Award is funded by an endowment from the Robert Wood Johnson Foundation. Gustav O. Lienhard was chair of the foundation’s board of trustees from the organization’s establishment in 1971 to his retirement in 1986 — a period in which the foundation moved to the forefront of American philanthropy in health care. Lienhard, who died in 1987, built his career with Johnson & Johnson, beginning as an accountant and retiring 39 years later as its president. Additional information about the Lienhard Award can be found here.

The National Academy of Medicine (NAM) today awarded 2017 Rhoda and Bernard Sarnat International Prize in Mental Health to Joseph Coyle, whose research laid the foundation for integrating neuroscience and clinical psychiatry and shifted psychiatry’s emphasis toward empirically based brain research; and to the team of Catherine Lord and Matthew State, whose work revolutionized the study of autism and related neuropsychiatric disorders.

Joseph Coyle’s work facilitated recognition of the central role of the brain in psychiatric disorders and by doing so improved the understanding and treatment of these disorders. His pioneering research illuminated some of the neurological mechanisms underlying Huntington’s disease, schizophrenia, and Alzheimer’s disease. For example, his research revealed that oxidative stress can lead to neural damage in schizophrenia and prompted the identification of acetylcholinesterase inhibitors as a treatment for Alzheimer’s disease. Coyle also made significant contributions to clinical psychiatry, transforming the Division of Child and Adolescent Psychiatry at Johns Hopkins into one of the country’s top divisions in this field and contributing to the literature on psychopharmacologic management of serious mental disorders in children. Coyle served as the chairman of the academic Department of Psychiatry at Harvard Medical School from 1991 to 2001, and is currently Eben S. Draper Professor of Psychiatry and Neuroscience at Harvard Medical School in Boston and McLean Hospital in Belmont, Mass.

Catherine Lord, director of the Center for Autism and the Developing Brain and professor of psychology in psychiatry and pediatrics at Weill Cornell Medicine in New York City, designed gold-standard diagnostic instruments for autism spectrum disorders that have facilitated genetic and neuroscientific research as well as clinical practice. Matthew State, Oberndorf Family Distinguished Professor, chair of psychiatry, and member of the Weill Institute for Neurosciences at the University of California, San Francisco, has leveraged these efforts to become a world leader in the study of autism genetics and genomics, directing several of the earliest highly successful large-scale genomic studies and discovering multiple genes that contribute to risk of these disorders. Together, Lord and State led an innovative collaboration to create a publicly available repository of genetic and behavioral data on autism, involving nearly 3,000 individuals with autism and their families, which has revolutionized the study of autism and related neuropsychiatric disorders.

“Through their pioneering research and clinical work, Joseph Coyle, Catherine Lord, and Matthew State have made profound contributions to the understanding of a range of serious neuropsychiatric disorders,” said National Academy of Medicine President Victor J. Dzau.

Since 1992, the Sarnat Prize has been presented to individuals, groups, or organizations that have demonstrated outstanding achievement in improving mental health. The prize recognizes — without regard for professional discipline or nationality — achievements in basic science, clinical application, and public policy that lead to progress in the understanding, etiology, prevention, treatment, or cure of mental disorders, or to the promotion of mental health. As defined by the nominating criteria, the field of mental health encompasses neuroscience, psychology, social work, nursing, psychiatry, and advocacy.

The award is supported by an endowment created by Rhoda and Bernard Sarnat of Los Angeles. Rhoda Sarnat is a licensed clinical social worker, and Bernard Sarnat is a plastic and reconstructive surgeon and researcher. The Sarnats’ concern about the destructive effects of mental illness inspired them to establish the award. Nominations for potential recipients are solicited from Academy members, deans of medical schools, and mental health professionals. This year’s selection committee was chaired by Huda Akil, Ph.D., Gardner Quarton Distinguished University Professor of Neuroscience and Psychiatry and co-director, The Molecular & Behavioral Neuroscience Institute, University of Michigan. To learn more about the Rhoda and Bernard Sarnat International Prize in Mental Health, please click here.

The National Academy of Medicine (NAM) has selected five outstanding health professionals for the class of 2017 NAM Fellows. They were chosen based on their professional qualifications and accomplishments, reputations as scholars, and relevance of current field expertise to the work of the NAM and the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine. The fellows will collaborate with eminent researchers, policy experts, and clinicians from across the country during their two-year fellowship. They will help facilitate initiatives convened by the National Academies to provide nonpartisan, evidence-based guidance to national, state, and local policymakers, academic leaders, health care administrators, and the public.

“The NAM Fellowship is designed for health science scholars who are one to 10 years out from completion of a residency or receipt of a doctoral degree to participate hands-on in our process of providing health advice to the nation,” said Victor J. Dzau, president of the National Academy of Medicine. “Through this experience, the fellows will be able to build a network of mentors whom the fellows can call upon throughout their careers. They also will study health care challenges across a range of disciplines and viewpoints to develop sound health care strategies and policies.”

Each fellow will continue in his or her primary academic post while engaging part time over a two-year period in the National Academies’ health and science policy work. Each will work with an expert study committee or roundtable related to his or her professional interests, including contributing to its reports or other products. A flexible research stipend will be awarded to every fellow.

The overall purpose of the NAM Fellowship program is to enable talented, early career health science scholars to participate actively in the work of the Academies and to further their careers as future leaders in the field. For more information, please click here.

The National Academy of Medicine (NAM) today announced the election of 70 regular members and 10 international members during its annual meeting. Election to the Academy is considered one of the highest honors in the fields of health and medicine and recognizes individuals who have demonstrated outstanding professional achievement and commitment to service.

“These newly elected members represent the most exceptional scholars and leaders in science, medicine, and health in the U.S. and around the globe,” said National Academy of Medicine President Victor J. Dzau. “Their expertise will help our organization address today’s most pressing health challenges and inform the future of health and health care to benefit us all. I am honored to welcome these distinguished individuals to the National Academy of Medicine.”

New members are elected by current members through a process that recognizes individuals who have made major contributions to the advancement of the medical sciences, health care, and public health. A diversity of talent among NAM’s membership is assured by its Articles of Organization, which stipulate that at least one-quarter of the membership is selected from fields outside the health professions — for example, from such fields as law, engineering, social sciences, and the humanities. The newly elected members bring NAM’s total membership to 2,127 and the number of international members to 172.
Established originally as the Institute of Medicine in 1970 by the National Academy of Sciences, the National Academy of Medicine addresses critical issues in health, science, medicine, and related policy and inspires positive actions across sectors. NAM works alongside the National Academy of Sciences and National Academy of Engineering to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies of Sciences, Engineering, and Medicine also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding. With their election, NAM members make a commitment to volunteer their service in National Academies activities.

Newly elected regular members of the National Academy of Medicine are:

Mark E. Anderson, M.D., Ph.D., William Osler Professor of Medicine and director of department of medicine, Johns Hopkins University School of Medicine, Baltimore

Cornelia Isabella Bargmann, Ph.D., Torsten N. Wiesel Professor, The Rockefeller University; and president of science, Chan Zuckerberg Initiative, New York City

Mary T. Bassett, M.D., M.P.H., commissioner, New York City Department of Health and Mental Hygiene, Long Island City, N.Y

Christopher N. Bowman, Ph.D., James and Catherine Patten Endowed Chair and distinguished professor of chemical and biological engineering; and clinical professor of restorative dentistry, School of Dental Medicine, University of Colorado, Boulder

Elizabeth H. Bradley, Ph.D., president and professor of science, technology, and society, and of political science, Vassar College, Poughkeepsie, N.Y.

Neil Calman, M.D., M.M.S., president and chief executive officer, Institute for Family Health; and professor and system chair, Alfred and Gail Engelberg Department of Family Medicine and Community Health, Icahn School of Medicine at Mount Sinai, New York City

Anne Case, Ph.D., Alexander Stewart 1886 Professor of Economics and Public Affairs Emerita, department of economics, Woodrow Wilson School of Public and International Affairs, Princeton University, Princeton, N.J.

Tina L. Cheng, M.D., M.P.H., Given Foundation Professor of Pediatrics and director, department of pediatrics, Johns Hopkins University School of Medicine; professor of population, family, and reproductive health, Johns Hopkins Bloomberg School of Public Health; and pediatrician-in-chief, The Johns Hopkins Hospital, Baltimore

Christos Coutifaris, M.D., Ph.D., Celso Ramon Garcia Professor of Obstetrics and Gynecology and chief, division of reproductive endocrinology and infertility, Perelman School of Medicine, University of Pennsylvania, Philadelphia

Mona N. Fouad, M.D., M.P.H., senior associate dean for diversity and inclusion, School of Medicine; and professor and director, division of preventative medicine; and director, Minority Health and Health Disparities Research Center, University of Alabama at Birmingham, Birmingham, Ala.

Felicia Hill-Briggs, Ph.D., A.B.P.P., professor of medicine and physical medicine and rehabilitation, Johns Hopkins University School of Medicine; professor of health, behavior, and society, Johns Hopkins Bloomberg School of Public Health; professor of acute and chronic care, Johns Hopkins School of Nursing; and senior director of population health research and development, Johns Hopkins HealthCare, Baltimore

Yasmin L. Hurd, Ph.D., Ward Coleman Professor of Translational Neuroscience; director, Addiction Institute; and professor of psychiatry and neuroscience, Icahn School of Medicine at Mount Sinai, New York City

Nicholas Patrick Jewell, Ph.D., professor, School of Public Health and department of statistics, University of California, Berkeley

Olugbenga Ogedegbe, M.D., M.S., M.P.H., director, division of health and behavior, department of population health, School of Medicine; and associate vice chancellor for global network academic planning, New York University, New York City

Rebecca Onie, J.D., founder, Health Leads, Boston

Maria A. Oquendo, M.D., Ph.D., Ruth Metzler Professor and chair of psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia

Michael S. Parmacek, M.D., Frank Wister Thomas Professor of Medicine and chair, department of medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia

Ramon E. Parsons, M.D., Ph.D., director, Tisch Cancer Institute; and professor and chair, department of oncological sciences, Icahn School of Medicine at Mount Sinai, New York City

Rita F. Redberg, M.D., M.Sc., professor of medicine, division of cardiology, University of California, San Francisco

Therese S. Richmond, Ph.D., CRNP, FAAN, Andrea B. Laporte Professor of Nursing and associate dean for research and innovation, School of Nursing, University of Pennsylvania, Philadelphia

Dorothy E. Roberts, J.D., George A. Weiss University Professor of Law and Sociology, Raymond Pace and Sadie Tanner Mossell Alexander Professor of Civil Rights, and professor of Africana studies, University of Pennsylvania, Philadelphia

Flaura Koplin Winston, M.D., Ph.D., distinguished chair, department of pediatrics, and scientific director, Center for Injury Research and Prevention, The Children’s Hospital of Philadelphia; and professor of pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia

Lesley Regan, M.D., D.Sc., FRCOG, president, Royal College of Obstetricians and Gynaecologists, and head of department, Obstetrics and Gynaecology, Imperial College Faculty of Medicine, St Mary’s Hospital, Imperial College London, United Kingdom

Soumya Swaminathan, M.D., director-general, Indian Council of Medical Research, New Delhi, India